<include file="public@contact_us_head">
<div class="container-fluid">
    <div class="appoint-box">
        <div class="appoint-wrapper">
            <form class="appoint-form">
                <p class="title">行程安排</p>
                <div class="appoint-row row">
                    <div class="col-sm-12 col-md-6">
                        <label for="dwmc" class="col-form-label">单位名称：</label>
                        <input type="text" class="form-control" id="dwmc">
                    </div>
                    <div class="col-sm-12 col-md-6">
                        <label for="dfrs" class="col-form-label">到访人数：</label>
                        <input type="text" class="form-control" id="dfrs">
                    </div>
                </div>
                <div class="appoint-row row">
                    <div class="col-sm-12 col-md-6">
                        <label for="nmz" class="col-form-label">男：</label>
                        <input type="text" class="form-control" id="nmz">
                        <label class="col-form-label">名</label>
                        <label for="nmz2" class="col-form-label">女：</label>
                        <input type="text" class="form-control" id="nmz2">
                        <label class="col-form-label pr-5">名</label>
                    </div>
                    <div class="col-sm-12 col-md-6">
                        <label for="dfsj" class="col-form-label">到访时间：</label>
                        <input type="text" class="form-control" id="dfsj">
                    </div>
                </div>
                <div class="appoint-row row">
                    <div class="col-sm-12 col-md-6">
                        <label for="fcsj" class="col-form-label">返程时间：</label>
                        <input type="text" class="form-control" id="fcsj">
                    </div>
                    <div class="col-sm-12 col-md-6 justify-content-start">
                        <label class="col-form-label">是否接送：</label>
                        <div class="form-check form-check-inline">
                            <input class="form-check-input" type="radio" name="sfjs" value="">
                            <label class="form-check-label">不需要</label>
                        </div>
                        <div class="form-check form-check-inline">
                            <input class="form-check-input" type="radio" name="sfjs" value="">
                            <label class="form-check-label">需要</label>
                        </div>
                    </div>
                </div>
                <div class="appoint-row row">
                    <div class="col-sm-12 col-md-6">
                        <label for="jjdz" class="col-form-label">接机地址：</label>
                        <input type="text" class="form-control" id="jjdz">
                    </div>

                </div>
                <p class="title">行程目的</p>
                <div class="appoint-row row">
                    <div class="col-md-12">
                        <label for="sy" class="col-form-label">事由：</label>
                        <textarea type="text" class="form-control" id="sy" rows="3"></textarea>
                    </div>
                </div>
                <div class="appoint-row row">
                    <div class="col-sm-12 col-md-6">
                        <label for="hjrx" class="col-form-label">期望会见入选：</label>
                        <input type="text" class="form-control" id="hjrx">
                    </div>
                    <div class="col-sm-12 col-md-6">
                        <label for="bz" class="col-form-label">备注：</label>
                        <input type="text" class="form-control" id="bz">
                    </div>
                </div>
                <p class="title">联络信息</p>
                <div class="appoint-row row">
                    <div class="col-sm-12 col-md-6">
                        <label for="lxr" class="col-form-label">联系人：</label>
                        <input type="text" class="form-control" id="lxr">
                    </div>
                    <div class="col-sm-12 col-md-6">
                        <label for="lxdh" class="col-form-label">联系电话：</label>
                        <input type="text" class="form-control" id="lxdh">
                    </div>
                </div>
                <div class="appoint-row row">
                    <div class="col-sm-12 col-md-6">
                        <label for="email" class="col-form-label">E-mail：</label>
                        <input type="text" class="form-control" id="email">
                    </div>
                    <div class="col-sm-12 col-md-6">
                        <label for="yzm" class="col-form-label">验证码：</label>
                        <input type="text" class="form-control" id="yzm">
                    </div>
                </div>
                <div class="appoint-row row justify-content-center mt-5">
                    <button class="btn btn-danger mr-5" type="submit">提交</button>
                    <button class="btn btn-dark" type="submit">重置</button>
                </div>
            </form>
            <form class="appoint-form">
                <p class="title-suggest">留下宝贵的意见或建议，我们会做到更好！</p>
                <div class="appoint-row row">
                    <div class="col-md-12">
                        <label for="gxch" class="col-form-label">阁下称呼：</label>
                        <input type="text" class="form-control" id="gxch">
                    </div>
                </div>
                <div class="appoint-row row">
                    <div class="col-md-12">
                        <label for="lxdhua" class="col-form-label">联系电话：</label>
                        <input type="text" class="form-control" id="lxdhua">
                    </div>
                </div>
                <div class="appoint-row row">
                    <div class="col-md-12">
                        <label for="mail" class="col-form-label">E-mail：</label>
                        <input type="text" class="form-control" id="mail">
                    </div>
                </div>
                <div class="appoint-row row">
                    <div class="col-md-12">
                        <label for="lyan" class="col-form-label">留言：</label>
                        <textarea type="text" class="form-control" id="lyan" rows="3"></textarea>
                    </div>
                </div>
                <div class="appoint-row row">
                    <div class="col-md-12 justify-content-start">
                        <label for="yzma" class="col-form-label">验证码：</label>
                        <input type="text" class="form-control w100" id="yzma">
                        <img src="../../images/upload/index_code.jpg">
                        <span class="pl-3 changecode">看不清</span>
                    </div>
                </div>
                <div class="appoint-row row justify-content-center mt-5">
                    <button class="btn btn-danger mr-5" type="submit">提交</button>
                    <button class="btn btn-dark" type="submit">取消</button>
                </div>
            </form>

        </div>
    </div>
</div>
<include file="public@common_footer">

</body>
</html>